TEXAS DEPARTMENT OF INSURANCE MEDICARE SUPPLEMENT REFUND CALCULATION FORM FOR CALENDAR YEAR

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Roberta Griffin
8 years ago
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1 Figure: 28 TAC (f)(3) TEXAS DEPARTMENT OF INSURANCE TYPE 1 SMSBP 2 For the State of Company Name NAIC Group Code NAIC Company Code Address Person Completing This Exhibit Title Telephone (I) (II) Earned Incurred Premium 3 Claims 4 Line 1. Current Year s Experience a. Total (all policy years) b. Current year s issues 5 c. Net (for reporting purposes) (line 1a line 1b) 2. Past Year s Experience (all policy years) 3. Total Experience (line 1c + line 2) 4. Refunds Last Year (excluding interest) 5. Refunds From All Previous Reporting Years (excluding interest) 6. Refunds Since Inception (excluding interest) (line 4 + line 5) 7. Benchmark Ratio Since Inception (Ratio 1 from worksheet) 3 Includes Modal Loadings and Fees Charged 4 Excludes Active Life Reserves 5 This is to be used as Issue Year Earned Premium for Year 1 of next year s Worksheet for Calculation of Benchmark Ratios

Premium 3 Claims 4 Line 1. Current Year s Experience a. Total (all policy years) b. Current year s issues 5 c. Net (for reporting purposes) (line 1a line 1b) 2.

2 TYPE 1 SMSBP 2 _ Company Name 8. Experienced Ratio Since Inception (Ratio 2) (line 3 col. II) / (line 3 col. I line 6) 9. Life Years Exposed Since Inception If (line 8 < line 7) AND (line 9 > 499), proceed; otherwise stop. 10. Tolerance Permitted (obtained from credibility table) Medicare Supplement Credibility Table Life Years Exposed Since Inception Tolerance 10, % 5,000 9, % 2,500 4, % 1,000 2, % % If less than 500, no credibility. 11. Adjustment to Incurred Claims for Credibility (Ratio 3) (line 8 + line 10) If line 11 > line 7, a refund/credit is not required, otherwise proceed. 12. Adjusted Incurred Claims (line 3, col. 1 line 6) x (line 11) 2 SMSBP = Standardized Medicare Supplement Benefit Plan Use P for pre-standardized plan.

Tolerance Permitted (obtained from credibility table) Medicare Supplement Credibility Table Life Years Exposed Since Inception Tolerance 10,000+ 0.0% 5,000 9,999 5.0% 2,500 4,999 7.

3 Type 1 SMSBP 2 _ Company Name 13. Refund [line 3, col. I line 6 (line 12/line 7)] If the amount on line 13 is less than.005 times the annualized premium in force as of December 31 of the reporting year, then no refund is made. Otherwise, the amount on line 13 is to be refunded or credited, and a description of the refund and/or credit against premiums to be used must be attached to this form. I certify that the above information and calculations are true and accurate to the best of my knowledge and believe. Signature Name Please Print or Type Title Date 2 SMSBP = Standardized Medicare Supplement Benefit Plan Use P for pre-standardized plan.

Otherwise, the amount on line 13 is to be refunded or credited, and a description of the refund and/or credit against premiums to be used must be attached to

4 REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIO SINCE INCEPTION FOR INDIVIDUAL POLICIES TYPE 1 SMSBP 2 Company Name NAIC Group Code NAIC Company Code Address Person Completing This Exhibit Title Telephone (a) 3 (b) 4 (c) (d) (e) (f) (g) (h) (i) (j) (o) 5 Earned Year Premium (Factor (b)x(c) Loss Ratio (d)x(e) Factor (b)x(g) Loss Radio (h)x(i) Policy Year Loss Ratio Total: (k): (l): (m): (n): Benchmark Ratio Since Inception: (l + n)/(k + m): (Ratio 1) 3 Year 1 is the current calendar year 1. Year 2 is the current calendar year 2 (etc.) Example: If the current year is 1991, then: Year 1 is 1990; Year 2 is 1989, etc.) 4 For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year. 5 These loss ratios are not explicitly used in computing the benchmark loss ratios. They are the loss ratios, on a policy year basis, which result in the cumulative loss ratios displayed on this worksheet. They are shown here for informational purposes only.

000 0.40 2 4.175 0.493 0.000 0.000 0.55 3 4.175 0.493 1.194 0.659 0.65 4 4.175 0.493 2.245 0.669 0.67 5 4.175 0.493 3.170 0.678 0.69 6 4.175 0.493 3.998 0.686 0.71 7 4.175 0.493 4.754 0.695 0.73 8 4.

5 REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIO SINCE INCEPTION FOR GROUP POLICIES TYPE 1 SMSBP 2 Company Name NAIC Group Code NAIC Company Code Address Person Completing This Exhibit Title Telephone (a) 3 (b) 4 (c) (d) (e) (f) (g) (h) (i) (j) (o) 5 Earned Year Premium (Factor (b)x(c) Loss Ratio (d)x(e) Factor (b)x(g) Loss Radio (h)x(i) Policy Year Loss Ratio Total: (k): (l): (m): (n): Benchmark Ratio Since Inception: (l + n)/(k + m): (Ratio 1) 3 Year 1 is the current calendar year 1. Year 2 is the current calendar year 2 (etc.) Example: If the current year is 1991, then: Year 1 is 1990; Year 2 is 1989, etc.) 4 For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year. 5 These loss ratios are not explicitly used in computing the benchmark loss ratios. They are the loss ratios, on a policy year basis, which result in the cumulative loss ratios displayed on this worksheet. They are shown here for informational purposes only.

000 0.46 2 4.175 0.567 0.000 0.000 0.63 3 4.175 0.567 1.194 0.759 0.75 4 4.175 0.567 2.245 0.771 0.77 5 4.175 0.567 3.170 0.782 0.80 6 4.175 0.567 3.998 0.792 0.82 7 4.175 0.567 4.754 0.802 0.84 8 4.

RULES AND REGULATIONS Title 31 INSURANCE

2228 RULES AND REGULATIONS Title 31 INSURANCE INSURANCE DEPARTMENT [31 PA. CODE CH. 84c] Valuation of Life Insurance Policies The Insurance Department (Department) amends Chapter 84c (relating to valuation